October 24th 2023
By Ari Parker
Medicare covers both screening and diagnostic mammograms. Read our guide to learn more about how often they’re covered and how much Medicare pays.
Mammograms are an important part of breast cancer detection and the best way to catch breast cancer early. Early detection can also lead to more effective treatment. When breast cancer is detected while it’s still in the localized stage, there’s a 5-year survival rate of 99%!
The good news is that mammograms are covered by Medicare. How often depends on your age and gender as well as the type of mammogram needed. Keep reading to learn more about the different types of mammograms and how Medicare coverage works for each.
Mammograms are important for early detection of breast cancer, and early detection can lead to better health outcomes.
Medicare covers screening mammograms once every 12 months for women over the age of 40.
Medicare covers diagnostic mammograms when they’re medically necessary.
A mammogram is an X-ray of your breasts. Screening mammograms are generally ordered as a preventive measure for women over the age of 35, even if no signs or symptoms are present. This is because screening mammograms make it possible to see tumors that cannot yet be felt. Diagnostic mammograms are ordered when signs or symptoms of breast cancer are present. They provide a more detailed X-ray that can be used to confirm diagnosis.
It’s recommended that women perform regular self examinations of their breasts to check for lumps, but lumps aren’t the only sign of breast cancer. Other signs include:
Breast pain
Thickening of breast skin
Nipple discharge
Change in breast size or shape
These symptoms may also be signs of benign conditions, which is why diagnostic mammograms are important.
If you’re worried about radiation exposure, it’s good to know that mammograms require a very low dose of radiation. The low dose makes the risk of harm from radiation low.
One of the issues that may arise with a screening mammogram is a false-positive result. Radiologists may see abnormalities (including calcium deposits) when no cancer is actually present. This is why abnormal screening mammograms are followed by a diagnostic mammogram, ultrasound, and/or biopsy to confirm a breast cancer diagnosis.
You can learn more about other issues that may arise with mammograms, including overdiagnosis and false-negative results on cancer.gov.
Medicare defines three different types of mammograms: baseline, screening, and diagnostic. Each type is covered differently, so we’ll explain each.
Regardless of the type of mammogram you get, you’ll receive the full amount of Medicare coverage if your doctor accepts Medicare assignment. If you’re not sure if your doctor accepts assignment, ask your provider’s billing department to determine what amount you’ll be responsible for.
The costs shared below are what you’ll pay on Original Medicare. If you have a Medicare Supplement (Medigap) plan, your costs will be reduced. How much depends on your specific plan type.
Each Medicare Advantage plan has different deductibles, and coinsurance amounts. If you’re on a Medicare Advantage plan, take a look at your summary of benefits and speak with your health care provider’s billing department to understand your costs before you receive care. If you have any questions, our team of Medicare Advisors and Advocates are here to help! Give us a call at (855) 900-2427 to get help understanding your plan benefits.
How often they’re covered: once in your lifetime between the ages of 35-39
Your cost on Original Medicare: $0
A baseline mammogram is covered once in your lifetime for women on Medicare between the ages of 35-39. A baseline mammogram is a type of screening mammogram, but is considered “baseline” by Medicare due to age.
You’ll pay nothing for a baseline mammogram if your doctor or other health care provider accepts Medicare assignment.
How often they’re covered: once every 12 months for women 40 and older
Your cost on Original Medicare: $0
Screening mammograms are a form of preventive care. As we mentioned at the beginning of this guide, mammograms are used to detect breast cancer early. It’s important for women to get a screening mammogram once every 12 months to detect cancer that may not be discovered through breast exams.
You’ll pay nothing for a screening mammogram if your doctor or other provider accepts Medicare assignment.
How often they’re covered: more frequently than once a year, if medically necessary
Your cost on Original Medicare: 20% of the Medicare-approved amount
A diagnostic mammogram is ordered to confirm the presence of cancer. If you have any issues with your breasts, a diagnostic mammogram can help a doctor make an official diagnosis.
After you’ve met your annual Part B deductible, you’ll pay 20% of the Medicare-approved amount for a diagnostic mammogram (the 20% you owe is your coinsurance).
If you have questions about your Medicare coverage, regarding mammograms or any other healthcare services, we’re here to help! Our licensed Advisors and Medicare Advocates are here to help you choose the best Medicare options for your unique needs. We’ll also help you understand and use your Medicare insurance when you need it.
Schedule a free consultation or call us at (855) 900-2427 to get your questions answered and feel confident in your Medicare decisions.
